92 Decision Citation: BVA 92-29506
Y92
BOARD OF VETERANS' APPEALS
WASHINGTON, D.C. 20420
DOCKET NO. 92-14 536 ) DATE
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THE ISSUE
Entitlement to service connection for a psychiatric disorder.
REPRESENTATION
Appellant represented by: Public Advocate for Veterans
Affairs, Puerto Rico
WITNESSES AT HEARING ON APPEAL
The veteran and his mother
ATTORNEY FOR THE BOARD
R. E. Coppola, Associate Counsel
INTRODUCTION
The veteran served on active duty from March 28, 1978 to
April 24, 1978.
By a May 1979 rating determination, the San Juan, Puerto
Rico Regional Office (RO) denied entitlement to service
connection for a psychiatric disorder, characterized as a
nervous condition. The veteran was notified of that
determination by letter dated May 10, 1979; he did not
appeal.
This matter came before the Board of Veterans' Appeals
(Board) on appeal from a rating decision of February 1990
from the RO. The notice of disagreement was received in
March 1990. The statement of the case was issued in
July 1990. The substantive appeal was received in
July 1990. A personal hearing on appeal was held at the RO
in June 1991. The hearing officer issued a decision in
March 1992. By a March 1992 rating determination, the RO
confirmed and continued the prior denial of service
connection for a psychiatric disorder. Thereafter, a
supplemental statement of the case was issued in May 1992.
The appeal was received and docketed at the Board in
August 1992. The veteran has been represented during this
appeal by the Puerto Rico Public Advocate for Veterans
Affairs.
REMAND
The veteran seeks entitlement to service connection for a
psychiatric disorder. This claim was previously denied by
the RO in May 1979. The veteran was notified of that
determination but he did not appeal. By the February 1990
rating determination, the RO denied the veteran's
application to reopen his claim for service connection. The
RO held that the evidence submitted did not establish a new
factual basis for reconsideration of the previous decision.
Following a personal hearing at the RO, the hearing officer
held that new and material evidence had been submitted.
Thereafter, the RO denied the claim for service connection
based on all the evidence of record.
The evidence of record indicates that the veteran had been
treated by Luis J. Montalvo-Durano, M.D., in November 1978,
December 1978 and January 1979. A summary of that treatment
provides a diagnosis of acute schizophrenic reaction with
paranoid content, lucid but emotionally incapacitated. The
evidence also contains a certificate from the Centro de
Salud Mental, Caguas, Puerto Rico, which indicates that the
veteran was hospitalized in December 1978. On Department of
Veterans Affairs (VA) examination in March 1979, it was
noted that the veteran was referred to the VA Mental Health
Clinic after being seen at the Caguas Mental Health Center.
It does not appear that copies of the clinical records
associated with the treatment and hospitalization have been
requested or obtained for the claims folder. We believe
that additional development is necessary for adjudication of
the issue on appeal.
The record contains a copy of the veteran's educational
transcript from the Electronic Data Processing College of
Puerto Rico, Inc., showing he attended that institution
beginning in September 1977. It appears from that
transcript that the veteran withdrew from that institution
on March 27, 1978. It is unclear from the evidence whether
he actually attended classes at that institution in l978,
prior to entry into service, and under what circumstances
the veteran withdrew from that institution.
The record contains evidence from the National Personnel
Records Center showing that the veteran served on active
duty from March 28, 1978 to April 24, 1978. It also shows
that the veteran was separated from service under the
trainee discharge program as being either marginal or
non-productive. It is not clear from the record the exact
nature or the specific circumstances of the veteran's
separation from service approximately one month after
entry.
The record contains evidence submitted in support of the
veteran's claim that is written in Spanish. These documents
should be translated to English so that they may be given
full and fair consideration.
The VA has a duty to assist the veteran in the development
of facts pertinent to his claim. 38 U.S.C.A. § 5107(a)
(West 1991); 38 C.F.R. § 3.103(a) (1991). Under the
circumstances of this case, we are of the opinion that
additional development is required.
Accordingly, the case is REMANDED for the following actions:
1. The veteran should be given an
opportunity to submit any additional
evidence in support of his claim. At the
veteran's request, the RO should assist
him in obtaining such evidence, and the
veteran should execute and submit an
appropriate consent form for the release
of any private evidence to the VA. Any
evidence obtained should be made part of
the claims folder.
2. The RO should attempt to obtain
copies the specified treatment records
of Dr. Montalvo-Durano, GPO Box 4923,
San Juan, Puerto Rico, 00936, for the
period from November 1978 to January
1979. The RO should also request copies
of the veteran's complete medical
records, including hospitalization
records of December 1978, from the Centro
de Salud Mental, Caguas, Puerto Rico.
Record number 25798 should be referenced
in the request. The veteran should
execute written consent forms for the
release of these private clinical records
to the VA. Any evidence obtained should
be made part of the claims folder.
3. The RO should obtain copies of all VA
inpatient and outpatient treatment
records from the VA Mental Health Clinic,
San Juan, Puerto Rico, for the period
December 1978 to March 1979. Any
evidence obtained should be made part of
the claims folder.
4. The veteran should be requested to
execute and submit an appropriate consent
form for the release of records from the
Electronic Data Processing College of
Puerto Rico, Inc. The RO should then
contact the Electronic Data Processing
College of Puerto Rico, Inc., and request
copies of all records pertaining to the
veteran, including administrative and
health records, and any correspondence or
other documents pertaining to his
withdrawal from that institute. The
school should also be asked to certify
whether the veteran attended classes
during l978, prior to his withdrawal in
March l978. Any evidence obtained should
be made part of the claims folder.
5. The RO should obtain any service
personnel records pertaining to the exact
nature or the specific reasons for which
veteran was discharged from active
service. Any evidence obtained should be
made part of the claims folder.
6. The RO should have all evidence of
record which is written in Spanish
translated into English.
7. Thereafter, the RO should re-evaluate
the veteran's claim for service
connection for a psychiatric disorder.
If the benefit sought is not granted, the veteran and his
representative should be provided with an appropriate
supplemental statement of the case, and the case should be
returned to the Board for further appellate consideration.
No action by the veteran is required until he is contacted
by the RO.
BOARD OF VETERANS' APPEALS
WASHINGTON, D.C. 20420
*
JANE E. SHARP
PHILIP E. WRIGHT
*38 U.S.C.A. § 7102(a)(2)(A) (West 1991) permits a Board of
Veterans' Appeals Section, upon direction of the Chairman of
the Board, to proceed with the transaction of business
without awaiting assignment of an additional Member to the
Section when the Section is composed of fewer than three
Members due to absence of a Member, vacancy on the Board or
inability of the Member assigned to the Section to serve on
the panel. The Chairman has directed that the Section
proceed with the transaction of business, including the
issuance of decisions, without awaiting the assignment of a
third Member.
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board of Veterans' Appeals is appealable to the United
States Court of Veterans Appeals. This remand is in the
nature of a preliminary order and does not constitute a
decision of the Board on the merits of your appeal.